SLEEPINESS THE WHEEL

SLEEPINESS AT THE WHEEL White PaPer

SLEEPINESS AT THE WHEEL White Paper

Sleepiness at the Wheel WHITE PAPEr PrEFACE Improving road safety is a priority of the French Government. Among the various causes of road accidents, one of them is especially common on motorways: lack of alertness, which leads to inattention and sleepiness. Lack of alertness is responsible for one in three collisions resulting in deaths on the motorway network, although it is the safest of all road networks! This phenomenon is not fully grasped by the public. Therefore, it is essential to gain knowledge and raise the publics awareness as regards sleepiness at the wheel. In more general terms, sleepiness at the wheel remains underestimated both socially and culturally speaking, which is a major issue for road safety and public health. This white book, put together by the French Motorway Companies (ASFA) and the National Institute of Sleep and Vigilance (INSV), presents the most recent knowledge on the subject at both the French and European levels and provides a number of recommendations. By contributing to a better understanding of sleepiness at the wheel, this work will help promote the implementation of new prevention strategies, to further reduce the number of victims on the road. Our objective is to cut down to less than 2000 the number of deaths per year on French roads by 2020. Manuel VALLS French Minister of Interior

ASFA and INSV would like to express their deep thanks to the panel of European sleep experts who author this book. Most of them also participate in the research on traffic accidents associated with sleepiness in their own country and thus have contributed to enrich our knowledge and proposals for preventing from the consequences of sleepiness at the wheel. Torbjorn Akerstedt Stockholm, SUÈDE Claudio Bassetti bern, SUISSE Fabio Cirignotta milan, ITALIE Diego García-Borreguero madrid, ESPAGNE Marta Gonçalves porto, PORTUGAL Damien Léger paris, FRANCE Markku Partinen helsinki, FINLANDE Thomas Penzel berlin, ALLEMAGNE Pierre Philip bordeaux, FRANCE Joris C. Verster utrecht, PAYS-BAS Jim Horne loughborough, ROYAUME-UNI

Sleepiness at the Wheel WHITE PAPER ProFESSIoNAL ASSoCIATIoN of ToLL road CoMPANIES asfa is the French professional association comprising all actors involved in motorway exploitation and concession. company members operate about 9000 km of high safety and service level infrastructures. its corporate purposes are to: Defend the interests of the French toll-road industry communicate on issues relevant to the profession as a whole Negotiate on employment and social issues Develop non-commercial international relations carry out research and conduct surveys Since becoming the fi rst cause of motorway accidents, sleepiness at the wheel represents a major stake as regards to road safety. consequently, asfa and motorway operators have placed fi ghting this phenomenon at the heart of their safety program. www.autoroutes.fr and www.somnolence-au-volant.fr asfa@autoroutes.fr INSTITuT NATIoNAL du SoMMEIL ET de LA vigilance the French institut of Sleep and Vigilance (insv) was launched in 2000 by the French Sleep Society (SFrMS). its vocation is to promote sleep and its disorders as part of public health. its missions are to raise awareness, inform and educate on sleep and vigilance disorders. as a federative body, it brings together the entire sleep community: learned societies, patient associations and healthcare professionals. its board of directors is made up of doctors and researchers all sleep experts and leaders in their fi eld. this genuine French communication and prevention interface has invested much of its energy, during the past 12 years, into having sleep acknowledged as a central factor for individual and collective health. www.institut-sommeil-vigilance.org contact@insv.org

Sleepiness at the Wheel WHITE PAPEr TABLE of CoNTENTS TABLE of CoNTENTS EXECuTIvE SuMMArY INTroduCTIoN Claudio Bassetti and Damien Léger p. 13 p. 17 I- A. 1. 2. ANALYzINg SLEEPINESS AT THE WHEEL Sleep/wake characteristics and methods for measuring sleepiness Fabio Cirignotta, Thomas Penzel and Markku Partinen The sleep/wake cycle Measurement tools of daytime sleepiness Objective methods Subjective methods Test specially designed for evaluating sleepiness during driving : measurement of standard deviation of lateral position p. 23 p. 23 p. 23 p. 24 B. 1. 2. 3. 4. 5. Behavioural factors infl uencing alertness Tobjorn Akerstedt and Pierre Philip Sleep deprivation Irregular working schedules Task-related fatigue Length of task and time of day Situations combining several risk factors Professional drivers Young drivers p. 27 p. 27 p. 28 p. 29 p. 30 p. 30 C. 1. 2. 3. Morbidities aff ecting alertness Markku Partinen, Thomas Penzel and Damien Léger Sleep apnoea Insomnia Narcolepsy p. 31 p. 31 p. 32 p. 32

TABLE OF CONTENTS D. 1. 2. 3. 4. Effects of psychoactive medications Joris C. Verster and Diego García-Borreguero Minor tranquilizers Antipsychotics Antidepressants Anti-histamine drugs p. 33 p. 33 p. 34 p. 34 p. 35 E. 1. 2. Effects of psychoactive substances Diego García-Borreguero and Joris C. Verster Alcohol Cannabis p. 36 p. 36 p. 37 II- A. 1. 2. 3. METHODS TO FIGHT SLEEPINESS AT THE WHEEL On the manufacturer side : in-vehicle detection and warning devices Jim Horne Systems monitoring the vehicle Autonomous cruise control Pre-crash systems Lane departure warning systems Intelligent cars for the future Drivers sleepiness detection-based systems Camera-based systems Electroencephalography Capacitive Foils Steering wheel grip and other driving inputs Advanced integrated systems p. 39 p. 39 p. 39 p. 41 p. 42 B. 1. 2. Measures focusing on road infrastructure Jim Horne Rumble strips The presence of resting areas p. 43 p. 43 p. 43 C. D. Behavioural approaches to fighting sleepiness Pierre Philip and Jim Horne Measures focusing on employers Damien Léger p. 44 p. 47

TABLE OF CONTENTS III- A. 1. 2. 3. IMPLEMENTATION Legal aspects Markku Partinen and Jim Horne Determining limitations to motor vehicle usage in case of pathologies that can induce sleepiness Detecting and sanctioning sleepy drivers The case of commercial drivers p. 49 p. 49 p. 49 p. 50 p. 51 B. 1. 2. 3. European initiatives Damien Léger, Claudio Bassetti and Marta Gonçalves European Union orientations on road safety Recent European Union initiatives The DRUID project National campaigns in European Union countries The Belgian Pitstop campaign The Greek Eyes on the road campaign France : INSV poll on Coping with sleepiness at the wheel 2011 Portuguese campaign Driving sleepy can kill Going forward The PROLOGUE project The ITERATE project p. 51 p. 52 p. 53 p. 55 AUTHORS PROPOSALS BIBLIOGRAPHY LIST OF ABBREVIATIONS AUTHORS BIOGRAPHY p. 57 p. 59 p. 61 p. 63 The aim of the current booklet is to complement and update the data of Sleepiness at the wheel, Eranet transport - ENT Action Group 15, 2009, coordinated by Pr René Amalberti, Health care Adviser at HAS and Scientific director at the MACSF insurance group.

Sleepiness at the Wheel WHITE PAPEr EXECuTIvE SuMMArY EXECuTIvE SuMMArY Sleepiness at the wheel is one of the recently uncovered reasons behind a large proportion of fatal car crashes around europe. although it is often diffi cult to determine precisely how much responsibility can be attributed to sleepiness in certain traffi c accident situations, it is estimated to underlie about 20% of car crashes in europe. in this regard, national statistics have been put forward by a few european countries. in France, a preliminary report published in 2011 stated that from a total of 3970 fatal accidents that took place on French roads, 732 cases occurred on straight roads, 85% of which were related to sleepy driving. in the United kingdom, the national database indicates a low incidence of drowsy driving (around 4%) but this estimate is most certainly largely underestimated, probably due to the mode of reporting. in Germany, drowsiness is reportedly implicated in 25% of all fatal road accidents. in italy, although recent data are missing, sleepiness is estimated to be involved in about 22% of road accidents. in Scandinavian countries, a recent Swedish pilot study found that drivers admitted experiencing sleepiness in 15% of road crashes. in Finland, an analysis of the national database on road accidents from 1991 to 2001 found that 15.3% of accidents were related to fatigue/sleepiness. 13 While the loss of human lives and disability are the most affl icting consequences, sleepiness-related collisions also have a major economic impact. it is thus indispensable to better understand how and when sleeprelated traffi c accidents occur, and to anticipate new strategies to prevent them as effectively as possible.

EXECUTIVE SUMMARY In order to understand how sleepiness occurs, it is important to acknowledge certain central aspects of its biology. Sleep and wakefulness are essentially determined by two independent regulatory mechanisms: the body clock and sleep pressure. Both mechanisms can be involved in sleepy driving. The body clock is responsible for the 24-hour rhythm that regulates sleep and wakefulness: sleepiness peaks between 2 and 6 am and to a lesser extent between 2 and 4 pm, which explains the surge of sleep-related traffic accidents that occur during those particular time slots. In parallel, sleep pressure progressively increases during the day: the longer the trip, the higher the risk of sleepiness. Overall, the sleep/wake cycle is a response to the dynamic balance between both mechanisms. 14 When drivers are affected by sleepiness or fatigue, their performance can become seriously impaired, especially at attention and decision-making on the road. Several objective and subjective methods exist to measure sleeping at the wheel, but all have their limits: objective methods are able to reliably detect sleepiness but most of them need to be conducted in specific conditions -such as a sleep lab- that do not accurately reproduce real-life driving conditions. Subjective methods can help detect the risk of sleepiness in certain situations of day-to-day life and are easier to set up, but they cannot be used directly at the wheel. Besides the individuals internal sleep/wake mechanisms, a variety of external factors also influence sleepiness at the wheel and tend to add up exponentially. Some of them are behavioural: sleep deprivation, irregular working hours, length of time spent at the wheel, driving in monotonous environments. Sleep disorders like sleep apnoea, insomnia or narcolepsy, may severely impact daytime vigilance, but also pathologies that have the potential to trigger sleep disorders, such as depression for example. Certain medications (hypnotics, anxiolytics, antiallergic and antiepileptic drugs) also reduce alertness. Psychoactive substances such as alcohol or cannabis add their deleterious effects to sleep deprivation and fatigue in young drivers, thus further increasing the risk of sleepiness.

Sleepiness at the Wheel WHITE PAPER certain populations are considered particularly at risk since they combine several risk factors: shift workers, professional drivers and young drivers. to combat sleepiness at the wheel, several types of measures have been put in place and need to be expanded globally: on the manufacturer side, in-vehicle mechanisms have been invented to detect and inform drivers of signs of sleepiness or vigilance impairment. For instance: lane departure warning systems, but also systems monitoring driver-behaviour directly. because the safety and the full-reliability of these devices has yet to be established, drivers should not depend entirely on them but rely on their own insight to evaluate their sleepiness. indeed, the driver is responsible for his state of alertness at the wheel. on the side of road infrastructure: rumble strips, resting areas and less monotonous road designs are tools that have proven effective at keeping drivers alert. on the side of employers of commercial drivers: regulations concerning hours of service have been put in place. concerning driver behaviour: it is important to avoid sleep deprivation before taking the wheel, to choose certain times of the day rather than others if possible when hitting the road (for instance avoiding early morning hours -2 to 6 am -and mid-afternoon hours -2pm to 4pm), to take regular breaks and naps. these are effective measures on which the public needs to be further educated. 15 the legal aspects associated with sleepiness comprise another area that needs to be actively revisited. in this context, the role physicians can play in alerting patients at risk of sleepiness at the wheel because of pathology or medication they are on is essential, and more training is defi nitely needed to keep health care practitioners up to date on applicable driving laws. researchers and physicians should establish fair and accurate performance criteria to predict patients driving ability with various conditions: this may reduce the risk of motor vehicle crashes and protect others from arbitrary and possibly unfair licence revocation.

EXECUTIVE SUMMARY More campaigns targeting drivers, especially the at-risk populations, also need to be deployed, in combination with other interventions, such as enforcement of traffic laws and regulations. Such campaigns have recently been conducted in a few European countries and have proven to be effective at improving drivers knowledge on sleepiness and its risks. However, they have not appeared to significantly impact the rate of sleeprelated car crashes which is the ultimate goal. Other campaigns involving several European Union (EU) countries are currently on-going and have been designed to determine the efficacy of new in-car systems and to evaluate the behaviour of drivers using these systems. In all these domains, new approaches still need to be proposed and investigated. Hereunder are some of the authors proposals: 16 On campaigns/communication educational campaigns focusing on at-risk populations such as adolescents, professional drivers and shift workers Display of information on highways, especially during the most dangerous driving hours (e.g. afternoon, early morning hours), but also broadcasted on radio stations focusing on traffic information On training training of (future) drivers in driving school, through instructors in case of psychoactive drug use, information must be clearly provided by the physician on whether or not it is safe to drive. If sleepiness is a common adverse effect of the drug, patients must think of asking for alternative medication that does not impair driving On legal aspects Work on European legislation regarding drivers who suffer from diagnosed and acknowledged sleep disorders Detection and management of sleepiness among professional drivers, especially lorry-drivers On new directions improved detection of sleepiness better knowledge of determinants of dangerous behaviour

Sleepiness at the Wheel WHITE PAPEr INTroduCTIoN INTroduCTIoN Claudio Bassetti and Damien Léger according to the european commission s Directorate General for Mobility and transport, road deaths have been decreasing year by year across the whole european Union, with a 43% drop since 2001. however, traffi c accidents were still responsible for 30,900 road fatalities and 1.7 million injuries in 2010. to continue lowering these numbers, it is indispensable to better understand how and when traffi c accidents occur and to anticipate new strategies to prevent them. one of the reasons behind fatal car crashes includes sleepiness at the wheel, a phenomenon to which this report is dedicated. experts like to compare the effect of sleepiness at the wheel to those of alcohol (which itself is legally punished when associated with driving): studies have shown that driving following a sleepless night is equivalent to hitting the road with an alcohol blood concentration of 0.9 g/l, which exceeds legal limits in all eu-countries. 17 road accidents caused by a driver falling asleep at the wheel are particularly severe: they are very likely to result in death because of the uncontrolled speed of the car during the impact and the driver s failure to brake.

INTroduCTIoN Probability of an accident according to different risk factors Diabetes Psychological diseases Neurological diseases Myocardial infarction Epilepsy 17-19 pm sleep debt 0.5 g/l blood alcohol level Age > 75 years Age > 70 years Female < 25 years Male < 25 years 1.1 g/l 1.6 g/l 10-fold increase 40-fold increase 0 1 2 3 4 5 6 7 8 Relative risk 18 This table highlights that a blood alcohol level of 0.5 g/l doubles the risk of accidents compared to a blood alcohol level of a sober driver. A blood alcohol level of 1.1 g/l is associated with a 10-fold increased risk of accident and a blood alcohol level of 1.6 g/l is associated with a 40-fold increased risk of accident. Male drivers 25 years old and under are also at a signifi cantly higher risk of accident. Source: Epilepsy and driving in Europe. Final report of the Working Group on Epilepsy. Projet UE IMMORTAL, Publications R1.1 et R1.2. Adapted with permission. Unfortunately, sleepiness at the wheel is not uncommon. in France, for instance, a 2010 epidemiologic survey, based on telephone interviews of nearly 4,800 French drivers, showed that 1 in 3 participants reported experiencing at least one episode of severe sleepiness at the wheel during the previous year. More than 1 in 10 reported at least one near-miss accident in the previous year, half of which were sleep-related. collecting objective data concerning car crashes due to sleepiness is diffi cult, the main issue being it is often hard to estimate the state of a driver right before a crash. consequently, the proportion of fatigue-related accidents in police reports and accident databases from different jurisdictions varies greatly. here are some of the most recent statistics issued by a few european countries: FrANCE a preliminary report on traffi c accidents published in 2011 stated that from a total of 3970 deaths on French roads, 732 cases occurred on straight roads. among them, 85% were related to sleepy driving, the remaining 15% to distraction.

road DeathS by country (by million inhabitants) 84 66 28 146 236 81 107 51 88 97 202 48 90 45 62 61 32 31 145 76 145 85 45 159 130 102 76 64 114 119 134 62 163 53 121 66 74 109 111 140 79 68 125 66 124 102 136 54 172 116 41 36 112 62 140 75 Source: European Commission, State: July 2011. Adapted with permission.

INTRODUCTION The UK Data are scarce in the UK. In the national database, drowsy driving is reported in about 4% of all road crashes. However, the term fatigue is only used in very specific unequivocal situations by UK police officers. Thus, it is most probable that its incidence is largely under-estimated. In a 2004 publication, authors found that 17% of road traffic collisions were sleep-related. Germany Drowsiness is currently implicated in 25% of all fatal road traffic accidents in the country. In 2009, 4154 deaths were recorded on German roads, which is the lowest estimate since 1950. The figures peaked in 1970 with 21,332 road fatalities. Since then, the number of deaths on the road has fallen by around 80 per cent. According to scientific studies, material-damage amounting to some five billion euros is caused by sleepy drivers each year in Germany. Spain In a 2010 publication, authors reported the results of a survey, carried out by the Spanish Institute of Health and Safety in the Workplace, showing that 45% of road accidents are due to distraction, recklessness, absent-mindedness and lack of attention, which are all often related to a lack of rest/sleep. Italy 20 Recent data are scarce. Based on numbers put forward by the Italian National Institute of Statistics, a 2001 publication reported that between 1993 and 1997, 21.9% of road accidents were sleep-related. Sweden A recent pilot study found that in approximately 15% of crashes, drivers admitted experiencing sleepiness. When considering the most significant risk factors (i.e. remaining awake during more than 16 hours in a row, sleeping less than 6 hours during the 24 hours prior to departure, taking the road at 2-6 am or 2-4 pm, presenting sleep disturbances), around 35% of drivers fulfilled at least one of the criteria. In order to estimate the prevalence of driving while sleepy, the Swedish Transport Administration has been screening, on a yearly basis, a random sample of 11 000 people, asking if they had experienced severe sleepiness or if they had almost fallen asleep while driving in the past 12 months. The most recent results, dating from the 2011 survey, state that more than 15% of individuals reported experiencing sleepiness. The group reporting the highest prevalence was that of young drivers. Finland An analysis of the national database including about 1400 car drivers held legally responsible for a fatal road accident between 1991 and 2001 showed that 15.3% of cases were considered fatigue-related accidents. During the years 2006 to 2010, 17% of fatal motor vehicle accidents were due to fatigued drivers, which were responsible for 18% of deaths on the road.

Sleepiness at the Wheel WHITE PAPER EuroPE overall, sleepiness at the wheel is considered responsible for 20 to 25% of traffi c accidents occurring on european roads. While the loss of human lives and disability are the most affl icting consequences, sleepiness-related collisions also have a major economic impact. there have been occurrences of commercial-vehicle sleepiness collisions destroying bridges over interstate motorways, causing major disruption to the transportation system and to the economy in the USa. in 2011, the United States reported a $230 billion societal cost for motor vehicle crashes. Direct and indirect costs of car accidents amounted 160 billion in 2007 for the whole european Union. this cost is phenomenal and several experts share the opinion that sleepiness is not suffi ciently recognized and reported as a causal factor for road accidents, and that more efforts need to be deployed in this area. the following fi gure shows the weight of drowsy driving in fatal road accidents (up to 16.5%) in the 1999-2008 period in the USa. Percentage of crashes involving drowsy driving in the usa 20 Percent of crashes involving a drowsy driver 15 10 5 7.0 % Maximum injury severity in crash 13.1 % 16.5 % 21 0 All (n=47,597) Admitted to Hospital (n=14,056) Fatal (n=4,031) Estimated proportion of crashes involving a drowsy driver, by maximum injury severity in crash. Study population: crashes that involved a passenger vehicle that was towed from the scene, United States, 1999 2008. Adapted from BC Tefft: Prevalence of motor vehicle crashes involving drowsy drivers, United States, 1999-2008 Accident Analysis & Prevention, 2012, vol 45, 180-6 with permission. how do we analyse sleepiness at the wheel what causes it, how do we measure sleepiness, and who are the populations most at risk? these are some of the questions chapter 1 explores. it also goes through several of the behavioural factors infl uencing alertness such as sleep deprivation, irregular working schedules, timing and length of driving but also factors such as medical conditions or the use of psychoactive substances and medication.

INTRODUCTION Chapter 2 summarizes some of the countermeasures that have been put forward so far to fight against sleepiness at the wheel. After focusing on in-vehicle detection and warning devices that have been put in place in recent years, the report goes into describing measures targeting road infrastructure, driver behaviour and employer awareness. In Chapter 3, some of the major legal aspects that are still necessary to bring forward are presented, as well as examples of European-wide and national campaigns, which can serve as bases for upcoming initiatives. To conclude, lead European sleep experts present 15 proposals to implement effective new countermeasures to further decrease the prevalence of sleeprelated-accidents in Europe. 22

Sleepiness at the Wheel WHITE PAPEr CHAPTEr I ~ Analyzing sleepiness at the wheel Chapter I ANALYzINg SLEEPINESS AT THE WHEEL A. Sleep/wake characteristics and methods for measuring sleepiness Fabio Cirignotta, Thomas Penzel and Markku Partinen 1. THE SLEEP/WAkE CYCLE Sleep provides the body and mind with the necessary time to rest, recuperate and reenergize for the next day. in the adult general population, seven to eight consecutive hours are considered a healthy length of time spent asleep. During the wake period, signs of sleepiness indicate the likelihood of falling asleep. 23 Sleep and wakefulness are essentially determined by two independent regulatory mechanisms: the body clock and sleep pressure (also known as sleep homeostasis): the body clock, physically located in the brain, is responsible for 24-hour rhythms, known as circadian rhythms, which control several functions including sleep and wakefulness. the circadian rhythm in sleepiness peaks in the early hours of the morning (2-6 am), with another rise mid-afternoon (2-4 pm). Sleep pressure is the amount of fatigue that accumulates progressively throughout the day, due to daytime cerebral/mental activity mainly. as waking duration increases, sleep pressure increases, which progressively increases the feelings of daytime sleepiness.

CHAPTER I ~ Analyzing sleepiness at the wheel The sleep/wake cycle is thus a response to the dynamic balance between both regulatory mechanisms. On top of these integrated factors of influence, sleepiness can be influenced by a variety of external factors, which tend to add up exponentially. Behavioural factors (such as a disturbed sleep-wake schedule), sleep disorders (for instance sleep apnoea syndrome), drugs (for instance hypnotics or anxiolytics) or alcohol intake all account for increased sleepiness. When drivers are affected by sleepiness or fatigue, their performance can become seriously impaired, especially at attention and decision-making. They are prone to a loss of alertness, difficulty keeping their eyes in focus, loss of concentration and wandering thoughts, reduced awareness of the environment and memory lapses. Individuals starts failing to check their rear view mirrors as frequently as they should, they present unconscious variations in speed, and erratic changing, drifting out of lanes. It is thus critical to identify the external factors influencing sleepiness to learn how to best manage them and reduce the likelihood of human error. 24 Before going into the details of the various factors influencing sleepiness, here is a short summary of the most common methods currently used to measure sleepiness at the wheel. This evaluation of sleepiness is indeed indispensable to better understand its pattern of occurrence, and to establish effective countermeasures for road safety. A variety of strategies have been proposed to evaluate the risk of drowsy-driving accidents. Some methods are cheap and easy to perform on a wide number of subjects, like the Epworth Sleepiness Scale (see page 26), while others are more expensive and timeconsuming. Some are performed in the laboratory, others can be performed in real-life situations, or in a driving simulator. The choice of method depends on the circumstances and purpose of those measurements. 2. Measurement tools of daytime sleepiness Objective methods Objective methods for measuring daytime sleepiness use a variety of physiological variables as indicators of an individual s drowsy state. These objective measurement tools are useful in that they are not influenced by possible self-reporting biases. The Multiple Sleep Latency Test and the Maintenance of Wakefulness Test Two objective clinical measures, The Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT), are sensitive predictors of daytime sleepiness and driving performance. The main difference between both methods is that MSLT involves lying in a dark room where the participant is instructed to initiate sleep, whereas the MWT involves sitting on a comfortable chair in a semi-dark room where the participant is instructed to try to avoid falling asleep. The sooner participants enters sleep, the higher their objective sleepiness rating. Brain activity is recorded during the test. One limitation in these approaches is that both tests provide a very different environment to that of driving, and do not require participants to conduct tasks similar to driving. Nonetheless, the MSLT and MWT have been found

Sleepiness at the Wheel WHITE PAPER to correlate with subjective sleepiness measures, driving performance indicators, and have shown sensitivity to sleep deprivation. Electroencephalography brain activity recorded via electroencephalography (eeg) can also be used out of the laboratory to evaluate sleepiness without the need for participants to actually fall asleep to achieve a measurement. this type of objective sleepiness measure may be more indicative of a participant s current state of sleepiness when at the wheel, and has been used in a number of sleeprelated on-road and simulated driving studies. video recording of eye movements in recent years, new methods based on eyelid movement and eye-closure have been specifi cally developed to measure drowsiness while driving. an increase in eye blink duration is associated with an increase in sleepiness. Similarly, an increase in slow eye movements and eye blink frequency are also associated with increasing sleepiness. one such method uses video recordings to determine the percentage of time an eye-lid remains closed at approximately 80% of total closure. a commercial drowsiness detector based on this technique is now available on the market. its sensor is placed on the dashboard and measures eyelid closure. in the commercial trucking industry, drivers using this detector not only receive a warning when they start becoming sleepy, this information can also be instantly relayed to fl eet managers. however, the sensitivity of this sensor is still questionable. an alternative method uses infrared refl ectance oculography to measure the relative velocity and duration of eyelid movements during blinks and especially the short-term variability of those characteristics. this relatively new drowsiness monitor is also commercially available. the system requires drivers to wear a special set of glasses that send and receive infrared light pulses to measure the velocity of the drivers eyelids. a computer system is installed to process this information and provide feedback on drowsiness in the form of a score displayed on the dashboard. here again, the sensitivity of the system needs to be further established. 25 Psychomotor vigilance Test another approach is based on the measurement of the drivers reaction time. one such test, the Psychomotor Vigilance test (PVt), is often used to assess commercial driver sleepiness in the United States. the PVt is based on a simple task where the subject presses a button as soon as a stimulus -such as a light- appears. the stimulus will turn on randomly every few seconds for 5 10 minutes. the purpose of the PVt is to measure sustained attention, and give a numerical measure of sleepiness by counting the number of lapses in attention of the tested subject. Limitations of current measurement tools these objective measures of sleepiness present important technical issues, which need to be addressed in further research to improve their use. of major importance is the diffi culty in differentiating levels of sleepiness and the specifi city of recordings, i.e., whether sleepiness, rather than attention, is actually being measured. in addition to these issues, physiological measures can be more time consuming, diffi cult to set up, and can be highly costly and relatively easily damaged.

CHAPTEr I ~ Analyzing sleepiness at the wheel Subjective methods The Epworth Sleepiness Scale one of the most commonly used methods for measuring sleepiness, the epworth Sleepiness Scale (ess), is quite different from the other methods described above, as it is based on a subjective approach. it is a scale intended to evaluate daytime sleepiness, measured using a short questionnaire. Subjects are asked to rate their likelihood of dozing off in different daily life situations. the higher the score, the higher the individual s level of daytime sleepiness. While this test does not provide a diagnostic in itself, the ess score can indicate the need to seek for expert medical advice. tests such as the ess have the advantage of not infl uencing the behaviour of the driver they do not constantly draw attention to his sleepiness. thus the ess has been extensively used as a research tool in studies of road crashes and driver impairment, however is less useful for the development of in-car sleepiness countermeasures. The Epworth Sleepiness Scale 0= no chance of dozing 2= moderate chance of dozing 1= slight chance of dozing 3= high chance of dozing 26 SITUATION CHANCE OF DOZING Sitting and reading Watching TV Sitting inactive in a public place (e.g a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL A score 10 indicates a significant reduction of alertness requiring a medical consultation. A score 16 indicates a pathological level of sleepiness.

Sleepiness at the Wheel WHITE PAPER other scales measuring sleepiness are the Stanford Sleepiness Scale and the karolinska Sleepiness Scale, which are less frequently used. Validity and reliability have been reported for both. Tests specially designed for evaluating sleepiness during driving: Measurement of standard deviation of lateral position Measuring the standard deviation of lateral position (SDlP) refl ects how well subjects maintain their lane position. it provides an index for each subject s road tracking error and ability to control the lateral motion of the vehicle. this test has a high test retest reliability, and thus can provide useful information on increasing sleepiness and decreasing attention at the wheel. SDlP is measured in centimetres, using an electro-optical device mounted on the rear of the vehicle that continuously records lateral position relative to lane-line delineation. as each measurement tool provides different types of information, they should be considered complementary. researchers should use these various approaches keeping the limits of each one in mind, choosing depending on their research objectives, time and resources. in conclusion, objective measurement tools are useful in that they are not infl uenced by possible self-reporting biases. however, some of these approaches, because they require participants to actually fall asleep to achieve a measurement, are impossible to implement in real-life situations. others can be cumbersome, time-consuming and expensive to set up. Subjective methods such as the epworth Sleeping Scale are easier to execute but do not provide a diagnostic per se. again, one of the major issues at play is whether sleepiness or another related concept is the dimension actually being measured. Studies have pointed out that this issue is already diffi cult at the individual level: subjective assessments made by drivers do not robustly relate to actual driving performance either in terms of judgments about alertness before the drive or ratings of performance after the drive. 27 B. Behavioural factors infl uencing alertness Tobjorn Akerstedt and Pierre Philip among the different types of factors infl uencing sleepiness, behavioural factors are the most common to occur in the general population. lack of sleep, long working hours and working during time-slots of low alertness, insuffi cient rest between work periods and excessive work load are among the main factors that can cause fatigue. 1. SLEEP deprivation Sleep deprivation is considered to be one of the primary causes of fatigue and sleepiness. consecutive nights of sleep deprivation -partial or totallead to what is called a sleep debt. if an individual s sleep debt becomes too important, he eventually goes to sleep, involuntarily. While it has long been known that total sleep loss can have a devastating impact on driving

CHAPTER I ~ Analyzing sleepiness at the wheel performances, recent research has shown that even one night of partial sleep deprivation (where sleep duration is restricted to four hours for instance) can significantly impair driving performance, as assessed by lane drift and the number of line crossings. In the mid-nineties, French sleep specialists reported that 50% of drivers reduced their sleep duration the night prior to a departure, while 10% didn t sleep at all. Interestingly, sleep reduction was associated with the duration of driving: the longer the trip was, the shorter the sleep episode during the night before departure. In 2002, a study showed that, for drivers having slept less than 5 hours in the past 24 hours, their risk of accidents increased by 2.7 compared to drivers who respect a normal sleep schedule. A driver s sensitivity to sleep deprivation varies with age. A 2012 study in the United States found that younger male drivers (between the ages of 20 and 25) are more susceptible to the effects of sleep restriction than older male drivers (aged 50 to 75). 28 Sleep complaints are indeed common during adolescence. Adolescents are physiologically predisposed to developing chronic sleep deprivation because of maturation changes in their circadian and homeostatic regulation systems. This leads to a delay in the timing of sleep and a consequent accumulation of chronic sleep debt. Adolescents complaints may also reflect lifestyle factors affecting sleep quality. Despite sleep-research data indicating that adolescents require 9 to 10 hours of sleep per night, youths sleep significantly less. Moreover, studies led in 2010 have suggested that even if young people are aware of sleepiness-related risks, they do not correctly perceive sleepiness while driving. As a consequence, younger drivers are more at risk for sleep-related accidents. According to a 2011 study led by the American Automobile Association s Foundation for Traffic Safety, drivers aged 16-24 are nearly twice as likely to be involved in a drowsy driving crash than drivers aged 40-59. In addition to their high sensitivity to sleep deprivation, young drivers may also accumulate inadequate experience at wheel, a tendency to adopt ineffective strategies against drowsiness, a propensity for enhanced risktaking behaviours. 2. Irregular working schedules About 20% of the working population is engaged in shift work and other irregular working hour arrangements. A number of shift workers suffer from what is known as Shift Work disorder. The main diagnostic criteria for this disorder are insomnia during daytime, sleep and excessive sleepiness during working hours. The fixed programming of the human body clock is the key reason as to why it can be harder to sleep during the day than at night. External factors such as noise, light, etc. can be other influencing factors. The prevalence of this disorder is estimated to reach 2 to 5% of the general population, which is probably an under-estimate. Studies led in 2009 have reported that shift workers have a high risk of falling asleep behind the wheel, of near-miss accidents and actual accidents, compared to regular daytime workers. Especially night shift workers, rotating

Sleepiness at the Wheel WHITE PAPER shift workers and those working extended shifts are at risk. a 1999 study led by the american automobile association s Foundation for traffi c Safety found that for night shift workers, the risk of having a sleep related accident was almost six times higher than having a non-sleep related accident. the most extreme fi ndings come from focus group interviews on intensive care nurses working 12h shifts. an alarming 95% reported automobile-related injuries and near-miss accidents that occurred during their commute to and from work. Major findings on commuting shift workers high prevalence of sleepiness and nodding off when driving home after night shifts and rotating shifts Struggle to stay awake at work, exhaustion and number of consecutive shifts can predict drowsiness and near-miss accidents after shiftwork extended shifts increase the risk of crashes and near-miss accidents the risk of falling asleep behind the wheel increases with the number of extended shifts per month long driving distances after shift-work are related to severe sleepiness Sleep durations below 6-7 hours are associated with sleep-related crashes Adapted from Mets M A J et al Shift work and traffi c safety, 2010, 80-89 with permission. 29 3. TASk-rELATEd FATIguE Most studies concerning driver fatigue -and consequent sleepiness- focus on sleep deprivation or circadian rhythm effects, but require drivers to perform driving tasks during monotonous conditions. this confounds the effects of sleep-related fatigue (Sr fatigue) and what is known as task-related fatigue (tr fatigue). task-related fatigue is caused by driving itself and by the driver s environment. experts make a difference between active and passive task-related fatigue. active fatigue is the most common form of task-related fatigue, occurring when demanding situations accumulate, such as high-density traffi c, poor visibility or the need to complete an auxiliary task (i.e. searching for an address) in addition to driving. Passive fatigue develops when a driver is mainly monitoring an uneventful, predictable, and repetitive driving environment over an extended period of time. While safe handling of a vehicle requires sustained attention, monotony leads to the opposite: arousal levels decline and are replaced by inattention and sleepiness. according to a French study published in 2010, this type of vigilance impairment has been identifi ed as one of the main contributing factors to road crashes, and is estimated to be involved in 20 to 30% of these crashes. the authors report that the effects of monotony occur in the 40 minutes

CHAPTER I ~ Analyzing sleepiness at the wheel following initiation of task. The results show that driving performance impairment increased most during the first 10 to 15 minutes for a range of metrics (heart rate variability, speed and skin conductance for instance), while other were impacted constantly throughout the experiment (lane lateral positioning, steering wheel movement and blink frequency for instance). 4. Length of task and time of day Long periods of uninterrupted driving have been associated with higher rates of accidents. More precisely, studies have shown that the duration of driving seems to significantly increase the risk of accidents at night and in the early hours of the morning. 5. Situations combining several risk factors In most cases, road accidents combine several factors: a lack of sleep, the length of the trip, a monotonous road, driving during the times of day when sleepiness peaks, bad environmental conditions, such as poor visibility and/ or use of psycho-active substances or medications. Some sub-populations are more prone than others to accumulate risk factors for daytime sleepiness and are therefore at a higher risk of accidents: professional drivers and youngsters are good examples. Professional drivers 30 Because of increasing productivity requirements, professional drivers (drivers of lorries, coaches and company cars) are highly exposed to sleep deprivation, to a modification of their sleep-wake schedule, to long uninterrupted periods of driving and to task-related fatigue and sleepiness. For instance, a 2002 study reported that 12% of truck drivers sleep less than six hours a day and that 17% of them stay awake for more than 16 hours. A UK study led in 2010 analysed the prevalence of excessive daytime sleepiness and accident rates among bus drivers. The results show that 20% of all bus drivers had an Epworth sleepiness score >10, which represents a significant level of sleepiness. 8% of drivers reported falling asleep at the wheel at least once a month, 7% reported experiencing a sleep-related accident and 18% a near-miss accident due to sleepiness while driving. The period in the 24-hour when the risk of traffic accidents is at its highest for a truck driver is during times of postprandial drowsiness. It is even greater outside normal working hours and, in particular, at the end of the night. Young drivers According to the authors of an Italian study published in 2011, road crashes are considered to be the first cause of death in people aged 10-24 years in developed countries. Indeed, young drivers tend to accumulate several risk factors. First of all, they represent the population most prone to sleep deficiency. A study led in 2010 on about 340 adolescents reported that 19% percent of the sample complained of bad sleep, 64% complained of daytime sleepiness, and 40% reported sleepiness while driving. Their analyses confirmed the high prevalence of sleep-related complaints among high-school

Sleepiness at the Wheel WHITE PAPER adolescents and highlighted their independent role on self-reported crash risk. Youngsters also tend to overestimate their driving abilities. Finally, it is common knowledge that they also tend to engage more frequently in certain risky behaviours, such as drunk driving and driving under the infl uence of cannabis (see e). Studies have indicated that younger age, lack of experience driving and consumption of alcohol and illegal drugs, especially on weekend evenings, are the main risk factors of sleep related traffi c crashes. C. Morbidities aff ecting alertness Thomas Penzel, Markku Partinen and Damien Léger all sleep disorders whether they generate a lack of sleep, an excess of sleep or bad quality sleep end up affecting daytime alertness. in 2007, a study led by asfa (published in December 2009 in the journal Sleep research) evaluated at the impact of sleep disorders on driving skills. the researchers had 35 000 questionnaires fi lled out by a population of frequent motorway users in France. results show that 16.9% of drivers complained of at least one sleep disorder (5.2% obstructive sleep apnoea, 9.3% insomnia, 0.1% narcolepsy and hypersomnia). 8.9% of drivers reported at least one episode per month of sleepiness at the wheel so severe they had to stop driving. the highest risks of accident were found among subjects suffering from narcolepsy and hypersomnia or multiple concomitant sleep disorders. Different sleep disorders are presented in this section, but other non-sleeprelated pathologies can lead to sleep disorders and this also affect sleepiness. 31 1. SLEEP APNoEA according to a 2008 epidemiological study, obstructive sleep apnoea is present in approximately 3% to 7% of adult men and 2% to 5% of adult women in the general population, in europe and in the United States. Disease prevalence is higher in certain subsets of the population, including overweight individuals and the elderly. Sleep apnoea is characterized by the frequent occurrence of abnormal pauses in breathing during sleep. these pauses may last from ten seconds to one or two minutes. Subjects with severe forms of sleep apnoea have more than 30 apnoea events per hour of sleep, and they can appear up to 90 times an hour. these pauses frequently generate awakenings, or so called microawakenings, which lead to non-restorative sleep and eventually to a reduction of attention, alertness and sleepiness during the day, resulting in an increased risk of sleep-related accidents. in 2008, a large US study showed that the risk of being in a car crash is two to fi ve times higher in individuals with sleep apnoea. individuals with sleep apnoea are rarely aware of their ailment, due to the sleepiness itself, and symptoms may be present for years or decades before they are identifi ed. the problem is usually brought forward by a bed companion disturbed by the loud snorts or choking sounds that follow each

CHAPTER I ~ Analyzing sleepiness at the wheel breathing pause. A test using polysomnography in a sleep laboratory enables to diagnose the disorder. Several studies have shown that treating sleep apnoea by Continuous Positive Air Pressure (CPAP) reduces sleepiness and the risk of motor vehicle collisions. 2. Insomnia Insomnia is the most common sleep disorder affecting millions of people as either a primary or comorbid secondary to another pathology- condition. Epidemiological studies have shown that it is reported by 20% to 30% of the adult general population. Insomnia is defined as a difficulty in falling asleep and/or maintaining sleep, occurring at least three times a week for at least one month and resulting in daytime impairment. It is primary when no other cause is found for these symptoms. In many cases though, insomnia accompanies another disease, which may be somatic (pain, metabolic disease) or psychiatric, such as anxiety or depression. Insomnia can also be the result of medication side effects or have a toxic origin (alcohol). Whatever the cause, patients with insomnia are affected by persistent difficulty falling asleep, staying asleep or by sleep of poor quality. This debt in restorative sleep inevitably leads to impairments in daytime functioning and to sleepiness, which again have a negative influence behind the wheel. 32 The 2007 Sleep in America poll reported that individuals with insomnia are three to five times more prone to accidents in general, and two and half times more in case of motor vehicle accidents. The connection between insomnia and the risk of road accidents has been well documented. Finally all types of pathologies leading to sleep restriction or deprivation can, as a consequence, give rise to somnolence and drowsy driving. 3. Narcolepsy Narcolepsy is a rare disease affecting less than 0.01% of the general population. Its main characteristic is excessive daytime sleepiness even after an adequate night sleep. A person with narcolepsy is likely to have unavoidable episodes of sleepiness and to fall asleep several times throughout the day, often in inappropriate times and places. Daytime naps occur with little warning and can become physically irresistible. Patients fall quickly into what appears to be very deep sleep, and wake up suddenly with a strong disorientation feeling. These naps are typically refreshing, but only for a few hours and drowsiness may persist for prolonged periods of time. Another typical feature of narcolepsy is cataplexy, which is characterized by sudden loss of muscle tonus. It is triggered by emotions and can lead to sudden falls. It may also dangerously affect driving. The authors of Narcolepsy: A Clinical Guide, published in 2010, report that driving simulator studies and psychological tests have proved that untreated narcolepsy can significantly impair driving performance and lead to an increased risk of car crashes. However, studies in real traffic remain scarce.